Type 2 Diabetes Performance Improvement Initiative: Chart ... ?· Performance Improvement Initiative:…

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<ul><li><p>1</p><p>Type 2 Diabetes Type 2 Diabetes Performance Performance </p><p>Improvement Initiative:Improvement Initiative:Chart ReviewsChart Reviews</p><p>Lara ZisblattLara ZisblattBoston University School of Boston University School of </p><p>MedicineMedicineBoston, MABoston, MA</p><p>22</p><p>Participants in the ProgramParticipants in the Program</p><p>487 people registered487 people registered</p><p>217 people started the program217 people started the program</p><p>182 people started their initial chart review182 people started their initial chart review</p><p>35 people completed their initial chart 35 people completed their initial chart reviewreview</p><p>22 people are working on their Action Plans22 people are working on their Action Plans</p><p>3 people completed the program3 people completed the program</p><p>33</p><p>Examples of Action PlansExamples of Action Plans</p><p> Screening all medical records for patients with type 2 diabetes Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C every 6 months and notifying them by phone if they need an A1C testtest</p><p> Creating an exercise plan worksheet for patients to write out Creating an exercise plan worksheet for patients to write out their exercise planstheir exercise plans</p><p> Providing patient education about the importance of selfProviding patient education about the importance of self--monitoring blood glucose levels; training the medical assistant monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and thatto check all meters to assure they are working properly and thatpatients know how to use thempatients know how to use them</p><p> Enrolling all type 2 diabetes patients in an education class Enrolling all type 2 diabetes patients in an education class available at the practiceavailable at the practice</p><p> Creating a registry of all patients with type 2 diabetes that woCreating a registry of all patients with type 2 diabetes that would uld track all tests necessary for these patientstrack all tests necessary for these patients</p><p> Use the diabetes care form to keep good records of patients withUse the diabetes care form to keep good records of patients withtype 2 diabetes and an excel form to track patientstype 2 diabetes and an excel form to track patients</p><p> Routine prescription for exerciseRoutine prescription for exercise Diabetes flow sheets in all charts Diabetes flow sheets in all charts Will move educational materials to exam roomsWill move educational materials to exam rooms</p></li><li><p>2</p><p>44</p><p>Action PlansAction Plans</p><p> Start simpleStart simple</p><p> Small changes can mean big improvements in patient Small changes can mean big improvements in patient carecare</p><p> Chart review is the first stepChart review is the first step</p><p> The tough part was getting started. Once I did The tough part was getting started. Once I did the first chart review, every review after became the first chart review, every review after became easier and faster.easier and faster.</p><p> The chart review was a great way for me to The chart review was a great way for me to systematically look at my practice. I could see systematically look at my practice. I could see how I was actually doing and not just how I how I was actually doing and not just how I thought I was doing.thought I was doing.</p><p>55</p><p>Type 2 Diabetes ProgramType 2 Diabetes Program</p><p>Make a commitment to yourself and to your Make a commitment to yourself and to your patients to work toward improving care!patients to work toward improving care!</p><p>Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement</p><p>For those of you who have completed chart For those of you who have completed chart reviews, please feel free to call us if you would reviews, please feel free to call us if you would like to discuss your plan for improvementlike to discuss your plan for improvement</p><p>If you have any questions, please email us at If you have any questions, please email us at mentorqi@bu.edumentorqi@bu.edu or call us at or call us at 617.638.4605617.638.4605</p><p>Applying What WeApplying What Weve ve Learned:Learned:</p><p>Patient Case Studies Patient Case Studies (Part 1)(Part 1)</p><p>Elliot Sternthal, MDElliot Sternthal, MDClinical Director, Diabetes Services Clinical Director, Diabetes Services </p><p>Boston Medical CenterBoston Medical CenterBoston, MABoston, MA</p></li><li><p>3</p><p>Mr. DMr. D</p><p>6969--yryr--old maleold male</p><p>1111--yr history of type 2 DMyr history of type 2 DM</p><p>Mild retinopathy, distal neuropathy, Mild retinopathy, distal neuropathy, microalbuminuriamicroalbuminuria, obesity, , obesity, coronary artery disease, hypertension, hypercholesterolemia, coronary artery disease, hypertension, hypercholesterolemia, dyslipidemiadyslipidemia, erectile dysfunction, erectile dysfunction</p><p> Current medication regimen:Current medication regimen:</p><p>GlipizideGlipizide ER 10 mg ER 10 mg qdqd, , metforminmetformin 1000 mg BID, HCTZ 25 1000 mg BID, HCTZ 25 mg mg qdqd, , valsartanvalsartan 160 mg 160 mg qdqd, , cardizemcardizem CR 120 mg CR 120 mg qdqd, , ASA 325 mg ASA 325 mg qdqd, , atorvastatinatorvastatin 20 mg 20 mg qdqd</p><p>Pertinent physical examination findingsPertinent physical examination findings</p><p> BMI 37, BP 114/58, rare retinal BMI 37, BP 114/58, rare retinal microaneurysmsmicroaneurysms, , vibratory perceptionvibratory perception</p><p>88</p><p>Mr. D Mr. D (cont(contd)d)</p><p>SelfSelf--care behaviorscare behaviors</p><p> SelfSelf--monitoring of blood glucose (SMBG): monitoring of blood glucose (SMBG): erratic, usually erratic, usually premealpremeal BG &gt;200 mg/BG &gt;200 mg/dLdL</p><p> Dietary: limited adherence, likes starches, Dietary: limited adherence, likes starches, occasional binges occasional binges </p><p> Physical activity: walking at moderate Physical activity: walking at moderate pacepace</p><p>Lab dataLab data</p><p> A1C 8.8%; mean FBG ~180; mean 2A1C 8.8%; mean FBG ~180; mean 2--hr hr PBG &gt;240PBG &gt;240</p><p>99</p><p>What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?</p></li><li><p>4</p><p>Clinical challenges: Clinical challenges: Improve preImprove pre-- &amp; postprandial BGs, &amp; postprandial BGs, promote weight loss, prevent recurrent CV eventspromote weight loss, prevent recurrent CV events</p><p>Desired treatment goals: Desired treatment goals: </p><p> PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140, 140, A1C 7% (? 6.5%)A1C 7% (? 6.5%)</p><p> BP 130/80 mm HgBP 130/80 mm Hg</p><p> LDL 40, TG </p></li><li><p>5</p><p>1313</p><p>Medication Addition:Medication Addition:What Are The Pros and Cons?What Are The Pros and Cons?</p><p>Add a Add a thiazolidinedionethiazolidinedione (TZD)?(TZD)?</p><p>Add an alphaAdd an alpha--glucosidaseglucosidase inhibitor?inhibitor?</p><p>Add a DPPAdd a DPP--4 inhibitor?4 inhibitor?</p><p>Add Add exenatideexenatide??</p><p>ExenatideExenatide AddedAddedEffect on overall glycemic control: Effect on overall glycemic control: </p><p>A1C to 7.1% after 3 monthsA1C to 7.1% after 3 months</p><p>Effect on postprandial glycemia: Effect on postprandial glycemia: 70 mg/70 mg/dLdL</p><p>Weight effect: Weight effect: 8 lb8 lb</p><p>1515</p><p>Ms. CMs. C</p><p>Recently immigrated to US; speaks rudimentary English</p><p>Lives with a cousin, works in housekeeping in a hotel</p><p>Recently diagnosed type 2 DM at walk-in clinic: random BG 255</p></li><li><p>6</p><p>1616</p><p>Ms. C Ms. C (cont(contd)d)</p><p>Pertinent physical examination findingsPertinent physical examination findings Wt 216, Ht 5Wt 216, Ht 566, BMI 35, BP 140/82, BMI 35, BP 140/82</p><p> Marked Marked acanthosisacanthosis nigricansnigricans and facial acneand facial acne No retinopathy or neuropathyNo retinopathy or neuropathy</p><p>SelfSelf--care behaviorcare behavior Little knowledge of diabetes or dietLittle knowledge of diabetes or diet No SMBGNo SMBG No exercise: too tired; works 50 hrs per weekNo exercise: too tired; works 50 hrs per week</p><p>1717</p><p>Ms. C Ms. C (cont(contd)d)</p><p>Lab DataLab Data</p><p>A1C 9%; urine A1C 9%; urine microalbuminmicroalbuminratio 10ratio 10</p><p>Hypercholesterolemia: LDL Hypercholesterolemia: LDL 122, HDL 57, TG 215122, HDL 57, TG 215</p><p>1818</p><p>What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?</p></li><li><p>7</p><p>Clinical Challenges: Clinical Challenges: Lack of diabetes educationLack of diabetes education</p><p>Goals:Goals:Nutrition counseling for Nutrition counseling for hyperlipidemiahyperlipidemia, weight loss, weight lossTeaching SMBG, DSMETeaching SMBG, DSME</p><p>Potential barriers to successful treatment:Potential barriers to successful treatment: Language/medical literacyLanguage/medical literacy Cultural/social beliefsCultural/social beliefs Economic concernsEconomic concerns Comprehension of her illness and treatmentComprehension of her illness and treatment Complex treatment programComplex treatment program Medication side effectsMedication side effects</p><p>2020</p><p>Desired treatment goals: Desired treatment goals: </p><p> PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140; A1C 6.5%140; A1C 6.5%--7%7%</p><p> BP 130/80 mm HgBP 130/80 mm Hg</p><p> LDL 50, TG </p></li><li><p>8</p><p>2222</p><p>Initial PlanInitial Plan</p><p>Start combination Start combination glyburideglyburide 1.25 1.25 mg/mg/metforminmetformin 250 mg 250 mg qamqam</p><p>ASA 81 mg ASA 81 mg qdqd??</p><p>2323</p><p>FollowFollow--Up:Up:3 months3 months</p><p>A1C 8.3%A1C 8.3%PrePre--breakfast BG 140breakfast BG 140--207207PrePre--dinner BGdinner BG 130130--180180Occasional 2Occasional 2--hr pc BG 170hr pc BG 170No hypoglycemia or excessive hungerNo hypoglycemia or excessive hungerForgets medication Forgets medication once or twice per weekonce or twice per weekWeight Weight 5 lbs5 lbsLDL 88, HDL 49, TG 138LDL 88, HDL 49, TG 138</p><p>2424</p><p>What Would You Do Next?What Would You Do Next?Pros and ConsPros and Cons</p><p>Increase Increase glyburide/metforminglyburide/metformincombination?combination?</p><p>Add a TZD?Add a TZD?</p><p>Add a DPPAdd a DPP--4 inhibitor?4 inhibitor?</p><p>Add Add exenatideexenatide??</p></li><li><p>9</p><p>2525</p><p>Increase Increase GlyburideGlyburide//MetforminMetformin</p><p>Glyburide/metforminGlyburide/metformin increased increased incrementally to 5 mg/1000 mg twice per incrementally to 5 mg/1000 mg twice per day over next 6 monthsday over next 6 months</p><p>A1C A1C 7.7%7.7%</p><p>2626</p><p>What Would You Do Next?What Would You Do Next?</p><p>Wait another 3 months?Wait another 3 months?</p><p>Add another medication?Add another medication?</p><p>Applying What WeApplying What Weve ve Learned:Learned:</p><p>Patient Case Studies Patient Case Studies (Part 2)(Part 2)</p><p>John R. White, PAJohn R. White, PA--C, C, PharmDPharmDProfessor of PharmacotherapyProfessor of PharmacotherapyWashington State UniversityWashington State University</p><p>College of PharmacyCollege of PharmacySpokane, WASpokane, WA</p></li><li><p>10</p><p>2828</p><p>Mr. JMr. J</p><p>5252--yearyear--old Caucasian maleold Caucasian maleType 2 DM X 12 years Type 2 DM X 12 years Also followed for obesity, hypertension, Also followed for obesity, hypertension, elevated lipidselevated lipidsMeds:Meds: MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years) GlimepirideGlimepiride 4 mg 4 mg qamqam (X 5 years)(X 5 years) Insulin Insulin glargineglargine 80 units 80 units qhsqhs EnalaprilEnalapril/HCTZ/HCTZ-- 10/25 10/25 qamqam AtorvastatinAtorvastatin 10 mg daily10 mg daily</p><p>2929</p><p>Mr. J Mr. J (cont(contd)d)</p><p>Working as a CPA for a tax firmWorking as a CPA for a tax firm</p><p>Walks for about 30 minutes 3x weeklyWalks for about 30 minutes 3x weekly</p><p>Admits to eating whatever he likes; has Admits to eating whatever he likes; has gained 4 lbs within last year gained 4 lbs within last year </p><p>SMBG values: only measures fasting; SMBG values: only measures fasting; usually in the 120usually in the 120--130 range130 range</p><p>BP 134/90 mm HgBP 134/90 mm Hg</p><p>Weight 230 lb; BMI 36Weight 230 lb; BMI 36</p><p>A1C value today is 8.2% A1C value today is 8.2% </p><p>3030</p><p>What Would Your Next What Would Your Next Treatment Decision Be?Treatment Decision Be?</p><p> Start a diet and exercise program? Start a diet and exercise program? </p><p> Add Add thiazolidinedionethiazolidinedione? Alpha? Alpha--glucose glucose inhibitor? inhibitor? ExenatideExenatide? ? SitagliptinSitagliptin??</p><p> Start a rapidStart a rapid--acting insulin analog (RAIA)?acting insulin analog (RAIA)?</p><p> Obtain more blood glucose data (fasting, Obtain more blood glucose data (fasting, preprandialpreprandial, postprandial)?, postprandial)?</p></li><li><p>11</p><p>3131</p><p>Mr. J: Mr. J: 3 Days of Intensive Monitoring3 Days of Intensive Monitoring</p><p>142142--164164</p><p>100100--148148</p><p>182182--198198</p><p>Low Low 130s130s</p><p>140140--146146</p><p>120120--134134</p><p>PostPost--dinnerdinner</p><p>PrePre--dinnerdinner</p><p>PostPost--lunchlunch</p><p>PrePre--lunchlunch</p><p>PostPost--breakbreak</p><p>FastFast</p><p>3232</p><p>What Insulin Program What Insulin Program Would You Initiate?Would You Initiate?</p><p> Split Split glargineglargine dose?dose?</p><p> Switch insulin to bid preSwitch insulin to bid pre--mix (70/30)?mix (70/30)?</p><p> Add 3 preAdd 3 pre--prandial RAIA injections?prandial RAIA injections?</p><p> Add Add preprandialpreprandial RAIA before the meal RAIA before the meal with the greatest glycemic excursion?with the greatest glycemic excursion?</p><p>3333</p><p>Mr. J: FollowMr. J: Follow--UpUp</p><p>RAIA added to regimen preRAIA added to regimen pre--lunch (started lunch (started with 4 units, eventually titrated to 8 units)with 4 units, eventually titrated to 8 units)</p><p>Patient consistently measures fasting and Patient consistently measures fasting and continues to periodically monitor precontinues to periodically monitor pre-- and and postprandial levelspostprandial levels</p><p>Patient was referred to a dietitian and has Patient was referred to a dietitian and has improved his dietimproved his diet</p><p>A1C value 3 months later is 7.2% A1C value 3 months later is 7.2% </p></li><li><p>12</p><p>3434</p><p>Ms. LMs. L</p><p>6262--yearyear--old female of Asian descentold female of Asian descentType 2 DM X 16 years Type 2 DM X 16 years Meds:Meds: MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years) GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years) 70/30 insulin70/30 insulin--30 units 30 units qamqam and 20 units and 20 units qpmqpm</p><p>3535</p><p>Ms. L Ms. L (cont(contd)d)</p><p>Currently teaches history in a middle Currently teaches history in a middle school school Eats a fairly consistent diet (low fat, Eats a fairly consistent diet (low fat, moderate protein and carbohydrate)moderate protein and carbohydrate)Participates in water aerobics twice Participates in water aerobics twice weekly, walks at lunchweekly, walks at lunchComplains of hypoglycemic episodes Complains of hypoglycemic episodes before and after lunch (50before and after lunch (50--80s), fasting 80s), fasting levels vary but are generally in the 150slevels vary but are generally in the 150sA1C value 9%A1C value 9%</p><p>3636</p><p>What Next ?What Next ?</p><p> D/C D/C glipizideglipizide or or metforminmetformin or both?or both?</p><p> Reduce the PM 70/30 dose?Reduce the PM 70/30 dose?</p><p> D/C 70/30 and start a longD/C 70/30 and start a long--acting acting analog?analog?</p><p> Reduce the AM 70/30 doseReduce the AM 70/30 dose</p></li><li><p>13</p><p>3737</p><p>Ms. L, Case continuedMs. L, Case continued</p><p>Meds:Meds: MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years) GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years) 70/30...</p></li></ul>

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